Premier Health Plan POLICY AND PROCEDURE MANUAL
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Premier Health Plan
POLICY AND PROCEDURE MANUAL
Policy Number: PA.205.PH
Last Review Date: 02/21/2019
Effective Date: 04/01/2019
PA.205.PH – Gender Reassignment
This policy applies to the following lines of business:
✓ Premier Employee
Premier Health Plan considers Gender Reassignment medically necessary for ALL of
the following indications:
1. The patient is at least 18 years old;
2. The patient has the mental capacity for fully-informed consent
3. The patient has been diagnosed with Gender Dysphoria (per the Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition (DSM-5) per the American
Psychiatric Association, see definition in Background section) and therefore
meets all the following indications:
a. The patient is participating in a recognized gender identity treatment group
b. The patient has the desire to live and be accepted as a member of the
opposite sex
c. The transsexual identity of the patient has been present persistently for at
least two years and is well-documented
d. Their gender dysphoria causes clinical distress or impairment in social,
occupational, or other important areas of functioning;
4. The patient has undergone a minimum of 12 months of continuous hormonal
therapy as appropriate to the patient’s gender goals (unless hormone therapy is
contraindicated)
5. The patient has completed 12 continuous months of living in the gender role that
is congruent with their gender identity
6. The patient has at least two referrals from qualified mental health professionals
(see definition in Background section) who have independently assessed the
patient
Limitations
1. Gender reassignment surgery is covered only once per lifetime. Transitioning
back to the natal gender is not a covered benefit.
2. Revisions after gender reassignment surgery are not covered unless there is a
complication which is life-threatening or prevents normal physiologic function.
3. If the patient has a significant medical condition or mental health concerns are
present, they must be reasonably well controlled and medically cleared for
surgery.
4. The following procedures may be considered cosmetic and therefore not
medically necessary:PA.205.PH – Gender Reassignment
Policy Number: PA.205.PH
Last Review Date: 02/21/2019
Effective Date: 04/01/2019
• Abdominoplasty
• Breast Augmentation (unless for MtF when an appropriate trial of hormone
therapy has not resulted in any breast enlargement)
• Blepharoplasty
• Brow lift
• Calf implants
• Cheek/malar implants
• Chin/nose implants
• Collagen injections
• Dermabrasion/Abrasion
• Drugs for hair loss or growth
• Electrolysis
• Eyelid plastic surgery
• Face-lift
• Facial feminization surgery
• Facial bone reduction
• Forehead lift
• Gluteal augmentation
• Jaw reduction (jaw contouring)
• Hair transplantation
• Hair removal
• Lip Reduction
• Liposuction
• Mastopexy
• Neck tightening
• Pectoral implants
• Reduction thyroid chondroplasty
• Removal of redundant skin
• Rhinoplasty
• Voice modification surgery
• Voice therapy/lessons
Background
The Centers for Medicare and Medicaid (CMS) define gender dysphoria, previously
known as gender identity disorder, as a classification used to describe persons who
experience significant discontent with their biological sex and/or gender assigned at
birth. Therapeutic options for gender dysphoria include behavioral and psychotherapies,
hormonal treatments, and a number of surgeries used for gender reassignment.
Page 2 of 7PA.205.PH – Gender Reassignment
Policy Number: PA.205.PH
Last Review Date: 02/21/2019
Effective Date: 04/01/2019
The Massachusetts Behavioral Risk Factor Surveillance Survey found 0.5% of the adult
population aged 18 to 64 years identified as Transgender and gender nonconforming
(TGNC) between 2009 and 2011.
DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents:
A. A marked incongruence between one’s experienced/expressed gender and assigned
gender, of at least 6 months duration, as manifested by two or more of the following:
a. A marked incongruence between one’s experienced/expressed gender and
primary and/or secondary sex characteristics (or, in young adolescents, the
anticipated secondary sex characteristics)
b. A strong desire to be rid of one’s primary and/or secondary sex characteristics
because of a marked incongruence with one’s experienced/expressed gender
(or, in young adolescents, a desire to prevent the development of the anticipated
secondary sex characteristics)
c. A strong desire for the primary and/or secondary sex characteristics of the other
gender
d. A strong desire to be of the other gender (or some alternative gender different
from one’s assigned gender)
e. A strong desire to be treated as the other gender (or some alternative gender
different from one’s assigned gender)
f. A strong conviction that one has the typical feelings and reactions of the other
gender (or some alternative gender different from one’s assigned gender)
B. The condition is associated with clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Characteristics of a Qualified Mental Health Professional: (From World Professional
Association for Transgender Health (WPATH, SOC-7):
A. Master’s degree or equivalent in a clinical behavioral science field granted by an
institution accredited by the appropriate national accrediting board. The professional
should also have documented credentials from the relevant licensing board or
equivalent; and
B. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the
International Classification of Disease for diagnostic purposes; and
C. Ability to recognize and diagnose co-existing mental health concerns and to distinguish
these from gender dysphoria; and
D. Knowledgeable about gender nonconforming identities and expressions, and the
assessment and treatment of gender dysphoria; and
E. Continuing education in the assessment and treatment of gender dysphoria. This may
include attending relevant professional meetings, workshops, or seminars; obtaining
supervision from a mental health professional with relevant experience; or participating
in research related to gender nonconformity and gender dysphoria.
Page 3 of 7PA.205.PH – Gender Reassignment
Policy Number: PA.205.PH
Last Review Date: 02/21/2019
Effective Date: 04/01/2019
Codes:
CPT/HCPCS Codes
Code Description
55970 Intersex surgery, male to female
55980 Intersex surgery, female to male
19301 Mastectomy, partial
19302 Mastectomy, partial with axillary lymphadenectomy
19303 Mastectomy, simple, complete
19304 Mastectomy, subcutaneous
19325 Mammaplasty, augmentation; with prosthetic implant
53430 Urethroplasty, reconstruction of female urethra
Urethroplasty with tubularization of posterior urethra and/or lower bladder
53431
for incontinence
54125 Amuptation of penis; complete
54400-54417 Penile prosthesis
Orchiectomy, simple (including subcapsular), with or without testicular
54520
prosthesis, scrotal or inguinal approach
54660 Insertion of testicular procedure (separate procedure)
54690 Laparoscopic, surgical; orchiectomy
55175 Scrotoplasty; simple
55180 Scrotoplasty; complicated
56625 Vulvectomy simple; complete
56800 Plastic repair of introitus
56805 Clitoroplasty for intersex state
56810 Perineoplasty, repair of perineum, nonobstetrical (separate procedure)
57106 - 57107,
Vaginectomy
57110 - 57111
57291 - 57292 Construction of artificial vagina
57335 Vaginoplasty for intersex state
Page 4 of 7PA.205.PH – Gender Reassignment
Policy Number: PA.205.PH
Last Review Date: 02/21/2019
Effective Date: 04/01/2019
58150, 58180,
58260 - 58262,
58275 - 58291, Hysterectomy
58541 - 58544,
58550 - 58554
58570 - 58573 Laparoscopy, surgical, with total hysterectomy
Laparoscopy, surgical; with removal of adnexal structures (partial or total
58661
oophorectomy and/or salpingectomy)
58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral
ICD-10 Codes
Code Description
F64-F64.9 Gender identity disorder
F64.1 Gender identity disorder in adolescents and adulthood
Z87.890 Personal history of sex reassignment
References
1. American Psychologist: American Psychological Association. (2015): Guidelines
for Psychological Practice with Transgender and Gender Nonconforming People.
Adopted by the Council of Representatives, August 5 & 7, 2015.
www.apa.org/practice/guidelines/transgender.pdf
2. American Psychological Association. Transgender, Gender Identity, & Gender
Expression Non-Discrimination.
http://www.apa.org/about/policy/transgender.aspx
3. Centers for Medicare and Medicaid (CMS) Services. Proposed Decision Memo
for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N). June
2, 2016. https://www.cms.gov/medicare-coverage-database/details/nca-
proposed-decision-memo.aspx?NCAId=282
4. Endocrine Treatment of Transsexual Persons: an Endocrine Society Clinical
Practice Guideline. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal
HA, Gooren LJ, Meyer WJ 3rd, Spack NP, Tangpricha V, Montori VM; Endocrine
Society. J Clin Endocrinol Metab. 2009;94:3132-54.
5. Hayes. Sex Reassignment Surgery for the Treatment of Gender Dysphoria.
August 1, 2018
6. Hayes. Ancillary Procedures and Services for the Treatment of Gender
Dysphoria. May 9, 2014. Annual Review: April 6, 2018.
Page 5 of 7PA.205.PH – Gender Reassignment
Policy Number: PA.205.PH
Last Review Date: 02/21/2019
Effective Date: 04/01/2019
7. Hayes. Hormone Therapy for the Treatment of Gender Dysphoria. May 19, 2014.
Annual Review: August 29, 2018.
8. Health Care for Transgender Individuals: Committee Opinion. Committee on
Health Care for Underserved Women; The American College of Obstetricians
and Gynecologists. Dec 2011, No. 512. Obstet Gyncol. 2011;118:1454-8.
9. National Institutes of Health Lesbian, Gay, Bisexual, and Transgender (LGBT)
Research Coordinating Committee. Consideration of the Institute of Medicine
(IOM) report on the health of lesbian, gay, bisexual, and transgender (LGBT)
individuals. Bethesda, MD: National Institutes of Health; 2013.
http://report.nih.gov/UploadDocs/LGBT%20Health%20Report_FINAL_2013-01-
03-508%20compliant.pdf
10. Report of the American Psychiatric Association Task Force on Treatment of
Gender Identity Disorder. Byne, W, Bradley SJ, Coleman E, Eyler AE, Green R,
Menvielle EJ, Meyer-Bahlburg HFL, Richard R. Pleak RR, Tompkins DA. Arch
Sex Behav. 2012; 41:759–96.
11. Standards of Care for the Health of Transsexual, Transgender, and Gender-
Nonconforming People (Version 7). Coleman E, Bockting W, Botzer M, Cohen-
Kettenis P, DeCuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer WJ,
Monstrey S, Adler RK, Brown GR, Devor AH, Ehrbar R, Ettner R, Eyler E,
Garofalo R, Karasic DH, Lev AI, Mayer G, Meyer-Bahlburg H, Hall BP, Pfäfflin F,
Rachlin K, Robinson B, Schechter LS, Tangpricha V, van Trotsenburg M, Vitale
A, Winter S, Whittle S, Kevan R. Wylie KR, Zucker K.
https://www.tandfonline.com/doi/abs/10.1080/15532739.2011.700873. Int J
Transgend. 2012;13:165–232.
12. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a
Foundation for Better Understanding. Robert Graham (Chair); Committee on
Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and
Opportunities. (Study Sponsor: The National Institutes of Health). Issued March
31, 2011. http://www.nationalacademies.org/hmd/Reports/2011/The-Health-of-
Lesbian-Gay-Bisexual-and-Transgender-People.aspx
13. World Professional Association of Transgender Health, formerly known as the
Harry Benjamin International Gender Dysphoria Association, Standards of Care
for Gender Identity Disorders, 7th version.
Disclaimer:
Premier Health Plan medical payment and prior authorization policies do not constitute
medical advice and are not intended to govern or otherwise influence the practice of
medicine. The policies constitute only the reimbursement and coverage guidelines of
Premier Health Plan and its affiliated managed care entities. Coverage for services
varies for individual members in accordance with the terms and conditions of applicable
Page 6 of 7PA.205.PH – Gender Reassignment
Policy Number: PA.205.PH
Last Review Date: 02/21/2019
Effective Date: 04/01/2019
Certificates of Coverage, Summary Plan Descriptions, or contracts with governing
regulatory agencies.
Premier Health Plan reserves the right to review and update the medical payment and
prior authorization guidelines in its sole discretion. Notice of such changes, if necessary,
shall be provided in accordance with the terms and conditions of provider agreements
and any applicable laws or regulations.
These policies are the proprietary information of Evolent Health. Any sale, copying, or
dissemination of said policies is prohibited.
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